A nurse is caring for an older adult client.

exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says. "Why don't you just leave me? I am of no use.”

• A. Heart rate: The client’s heart rate is elevated at 118/min, which could indicate blood loss, dehydration, pain, anxiety, or infection. This finding requires immediate follow-up to assess the cause and intervene as needed.
• B. Current medications: The client is taking ibuprofen 800 mg three times daily PRN for arthritis pain. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastric irritation, ulceration, and bleeding. This finding requires immediate follow-up to evaluate the client’s pain level, medication use, and possible alternatives to NSAIDs.
• C. Blood pressure: The client’s blood pressure is low at 90/50 mm Hg, which could indicate hypovolemia, shock, or cardiac dysfunction. This finding requires immediate follow-up to monitor the client’s fluid status, perfusion, and organ function.
• D. Stool results: The client’s stool tested positive for occult blood and H. pylori bacteria. Occult blood indicates gastrointestinal bleeding, which could be related to the client’s abdominal pain and weight loss. H. pylori is a common cause of peptic ulcer disease, which can also cause bleeding and pain. This finding requires immediate follow-up to confirm the diagnosis and initiate treatment with antibiotics and acid-suppressing drugs.

• H. Hemoglobin and hematocrit: The client’s hemoglobin and hematocrit are low at 9.1 g/dL and 27%, respectively. These values indicate anemia, which could be caused by chronic blood loss, nutritional deficiency, or bone marrow suppression. This finding requires immediate follow-up to determine the etiology and severity of the anemia and provide appropriate therapy such as blood transfusion, iron supplementation, or erythropoietin.

The other findings are not as urgent as the ones above:

• E. Respiratory rate: The client’s respiratory rate is normal at 18/min. There is no evidence of respiratory distress or hypoxia.
• F. WBC count: The client’s WBC count is normal at 6,700/mm3. There is no indication of infection or inflammation.
• G. Temperature: The client’s temperature is slightly elevated at 37.5° C (99.5° F), but not enough to warrant immediate concern. It could be due to stress, dehydration, or a mild infection. The nurse should monitor the temperature trend and report any significant changes or signs of sepsis.

Hypertonicity is a sign of increased muscle tone and stiffness, which can indicate that the newborn is experiencing withdrawal from methadone exposure in utero. Methadone is an opioid medication that can cross the placenta and cause neonatal abstinence syndrome (NAS) in the newborn.

Choice A is wrong because it is a normal finding in newborns.

Acrocyanosis is a bluish discoloration of the hands and feet due to immature peripheral circulation. It usually resolves within the first 24 to 48 hours of life.

Choice B is wrong because it is not a typical sign of withdrawal.

Bradycardia is a slow heart rate, usually less than 100 beats per minute in newborns. It can be caused by hypoxia, hypothermia, hypoglycemia, or vagal stimulation.

Choice C is wrong because it is a sign of increased intracranial pressure, not withdrawal. Bulging fontanels can be caused by meningitis, hydrocephalus, or hemorrhage.

Normal ranges for newborn vital signs are as follows:

• Heart rate: 120 to 160 beats per minute
• Respiratory rate: 30 to 60 breaths per minute
• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
• Blood pressure: 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic